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Revista argentina de cirugía

versión On-line ISSN 2250-639X

Rev. argent. cir. vol.112 no.4 Cap. Fed. dic. 2020

http://dx.doi.org/10.25132/raac.v112.n4.1551.ei 

Articles

Carbon dioxide filtering system for laparoscopic surgery in times of COVID-19 pandemic

Sebastián L. Jaimerena1  * 

Gonzalo Crosbie1 

Fernando Bellotti1 

Martín H. Quirós1 

Luciana Cantelmi1 

Omar García1 

Hernán Hoese1 

Analía del Sol Messere1 

1 Servicio de Cirugía Ge neral Complejo Médico Policial Churruca-Visca, Buenos Aires. Argentina.

Introduction

The COVID-19 pandemic has produced many changes in the management of surgical patients. The emergence of new knowledge and the dynamics of the pandemic led to changes in the protocols of care and also generated several discussions about the risks of the laparoscopic approach in patients with suspected or confirmed COVID-19, in view of the possible presence of the virus in carbon dioxide.

Based on national and international literature, our department considers continuing with laparoscopy as the approach of choice in certain conditions using a carbon dioxide filtering system described in this article.

Development

On December 31, 2019, the first case of COVID-19 was reported in the city of Wuhan (China). Since then, to date, it has turned into a pandemic with more than 30 million cases and over 900,000 deaths, without respecting nationality, ethnicity or ideology.

Several protocols have been developed for the hospitalization and care of surgical patients, prioritizing the global and institutional situation5,6,11.

Emergency surgeries cannot be delayed or canceled; they must always be guaranteed, considering the situation of each institution1,3.

Following international and national recommendations provided by the Asociación Argentina de Cirugía (AAC), the general guideline was not to change the approach, unless the context of the institution and the patient determined so. Each decision should be individualized and based on a definitive diagnosis1.

In case of choosing the laparoscopic approach due its advantages, the evidence of viral contamination and exposure of the staff during laparoscopy through the generation of aerosols should be considered1,3. The evidence of the risk of aerosolization of viral particles present in the pneumoperitoneum during a laparoscopy is limited to a single experience with the hepatitis B virus7,8. Obviously, at present there is only preliminary data available for SARS-CoV-2 and the experiences reported are limited to case reports or case series1,3.

Therefore, although there are no studies focused on the transmission of COVID-19 in laparoscopic surgery, it is of utmost importance to use carbon dioxide filtering systems during the surgical procedure1-3.

Carbon dioxide filtering systems have been developed by several manufacturers. Although these devices fulfill the requirements, their high cost, the impossibility of reusing them and the difficult access for our health care system made it necessary to look for alternatives with elements that are available in all the operating rooms.

The filtering system was developed following the recommendations established by the surgical associations1,2,4, with accessible elements usually present in the operating room. This system can be easily assembled at low cost and can be adapted to our health situation. The system should be ready before the patient enters the operating room.

The following description corresponds to the system used in our institution.

The necessary elements are (Fig. 1):

1. Twin-tube bottle

2. T-63 cannula (for CO2 insufflation)

3. T-95 cannula or similar

4. HMEF filter (electrostatic filter made up of charged bipolar rectangular split fibers to capture airborne particles). The composition of this material provides a high resistance and guarantees a long life, without significant degradation. Bacterial/viral filter efficiency: > 99.999%/ > 99.9%

5. Endotracheal tube (ETT) connector size 7 or 6 ½.

6. Elbow connector

Figure 1 A: twin-tube bottle. B: T-95 cannula. C: ETT connector size 7 or 6 ½. D: elbow connector + syringe. E: HMFE filter. 

This pneumoperitoneum filtering and evacuation system consists of:

1. A T-63 cannula (used for CO2 insufflation) (Fig. 2 A) connected to an HMEF bacterial/viral filter. An endotracheal tube connector size 7 or 6 ½ may be placed between them.

2. An elbow or elbow-like connector can be fitted between the distal limb of the filter and a T-95 cannula (Fig. 2 B) connected to a twin-tube container (Fig. 2 C).

3. The twin-tube underwater sealed bottle must contain a solution of quaternary ammonium or sodium hypochlorite (bleech) (Fig. 3 A).

4. The twin-tube container should be connected to the vacuum system (Fig. 3 B).

5. If the container is not sealed and does not have a non-return valve, a filtering device is necessary in the vacuum system. An HMEF filter must be placed between the container and the vacuum system (Figs. 4 A y B)

6. A trocar is used to insufflate carbon dioxide and another trocar is connected to the system for evacuating gas previously described. A two-way stopcock connected to the trocars coordinates insufflation and evacuation.

7. If possible, new trocars (disposable or non-disposable) or those in good conditions should be used to avoid unnecessary and accidental gas leakage. According to the conditions of the trocars (and their valves) it is recommended to evacuate carbon dioxide before removing or introducing instruments.

8. An HMEF filter can be connected to the insufflation system in case it lacks a non-return valve.

9. In addition to the carbon dioxide filtering system described above, it is necessary to follow the general recommendations for laparoscopic surgery in suspected or confirmed COVID-19 patients1,4,6.

▪▪Strict compliance with the use of personal protective equipment (goggles, gloves, scrub hat, show covers, N95 respirator, fluid resistant gown and disposable hood)5,9,10.

▪▪Strict adherence to transportation routes and circulation pathways of patients inside and outside the operating room (established by each institution)6,9,10.

▪▪The lowest pneumoperitoneum pressure should be used if it does not compromise the exposure of the surgical field1,8.

▪▪Minimize the number and size of the incisions for the trocars. Use the Veress needle for insufflation if possible2,11.

▪▪Avoid placing COVID+ patients in the Trendelenburg position for a long period to prevent adverse effects on the cardiopulmonary function2,3.

▪▪Limit the continuous use of power sources to minimize aerosolization1,2.

▪▪Consider use of drains only if strictly necessary (drains are not recommended in COVID-19 patients)2,3.

▪▪Achieve the maximum possible benefit with the smallest surgical gesture to minimize the probability of postoperative complications1,2,6.

▪▪The most experienced surgeon should be the leader of the surgical team, in order to minimize risks, complications, and time of exposure in the operating room2,3.

Figure 2 A: HMFE filter with valve in the distal end (white arrow), ETT connector size 7 or 6 ½ (long white arrow), T-63 cannula or similar (black arrow). B: Elbow or elbow-like connector (white arrow), T-95 cannula (black arrow). C: T-95 cannula connected to the twin-tube container (arrow). 

Figure 3 A: Twin-tube container with solution of quaternary ammonium or sodium hypochlorite. System working (arrow). B: The twin-tube con tainer connected to the vacuum system (arrow) 

Figure 4 A: connection to the filtering device and filtering system (white arrow), HMFE filter (black arrow), twin-tube container (long white arrow). B: connection to the filtering device and filtering system (white arrow), T-63 cannula or similar (black arrow). 

Conclusions

The carbon dioxide filtering system previously described is a simple and efficient method for evacuating smoke and aerosols. The system is easy to assemble and affordable: an HMEF filter costs approximately ARS135-150, and is readily available in all the operating rooms, unlike high-cost commercially manufactured filters which cost of up to USD20 per filter at the beginning of the pandemic; although they are currently less expensive, they are not readily available in our health care system.

This system allows the use of the laparoscopic approach in certain diseases during the COVID-19 pandemic.

Referencias bibliográficas /References

1. Asociación Argentina de Cirugía http://aac.org.ar/covid_inst_nac.asp. [ Links ]

2. Asociación Argentina de Cirugía. Comité de Cirugía videoendos cópica y mininvasiva. Recomendaciones generales en contexto de pandemia por Covid-19. http://aac.org.ar/covid_aac_19-5.asp http://aac.org.ar/covid_aac_22-5.aspLinks ]

3. Documentos de posicionamiento y recomendaciones de la AEC en relación con la cirugía y COVID-19. Asociación Española de Cirugía: https://www.aecirujanos.es/Documentos-de-posiciona miento-y-recomendaciones-de-la-AEC-en-relacion-con-la-cirugia-y-COVID19_es_1_152.htmlLinks ]

4. Francis N, Dort J, Cho E, et al. SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg Endosc. 2020 published on-line 22 April https://doi.org/10.1007/s00464-020-07565-wLinks ]

5. Gobierno de la República Argentina. Protocolo y Recomendaciones Sanitarias. https://www.argentina.gob.ar/coronavirus/protoco losLinks ]

6. Gobierno de España. Ministerio de Sanidad. Dirección Gene ral de salud pública, calidad e innovación. Centro de Coor dinación de Alertas y Emergencias Sanitarias. Procedimiento de Actuación frente a casos de Infección por el nuevo coronavirus (SARS-CoV-2), actualizado a 11 de marzo de 2020. [ Links ]

7. Kwak HD, Kim SH, Seo YS, Song KJ. Detecting hepati tis B virus in surgical smoke emitted during laparosco pic surgery. Occup Environ Med. 2016; 73(12):857-63. [ Links ]

8. Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifesta tions and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. pii: S0016-5085(20)30281-X. doi: 10.1053/j.gastro.2020.02.054. [ Links ]

9. Protocolo de utilización de Equipos de Protec ción. Hospital Universitario La Paz, Madrid. Recomendaciones para equipos de salud. Argentina.gob.ar: https://www.argentina.gob.ar/coronavirus/equipos-saludLinks ]

10. Sequence for putting on and removing Personal Protective Equip ment (PPE). Centers for Disease Control (CDC) https://www.cdc.gov/hai/prevent/ppe.htmlLinks ]

11. Surgical Care and Coronavirus Disease 2019 (COVID-19). Ameri can College of Surgeons https://www.facs.org/about-acs/co vid-19/information-for-surgeonsLinks ]

Received: July 14, 2020; Accepted: October 20, 2020

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